Fulminant simultaneous multiple dissections of the cervical and vertebral arteries leading to hemorrhagic and ischemic stroke: A case report

Abstract

Background: Intra-and extracranial artery dissections are uncommon but significant causes of ischemic stroke and subarachnoid hemorrhage (SAH). While individual dissections are well-documented, simultaneous dissections of multiple vessels leading to both hemorrhagic and ischemic strokes are extremely rare.

Case description: A 41-year-old man presented with acute onset of headache, vomiting, and loss of consciousness. Imaging revealed multiple arterial dissections involving the bilateral internal carotid arteries and vertebral arteries (VAs). The patient was diagnosed with SAH caused by a ruptured fusiform aneurysm in the left VA. Emergency endovascular trapping was performed to treat the ruptured VA aneurysm. The following day, ischemic infarctions were observed in both hemispheres, prompting the initiation of dual antiplatelet therapy for the cervical carotid artery dissection. Despite the complexity of his condition, the patient achieved functional recovery, with a modified Rankin Scale score of 3 at discharge.

Conclusion: Simultaneous hemorrhagic and ischemic strokes due to multiple arterial dissections pose significant diagnostic and therapeutic challenges. This case highlights the importance of individualized treatment strategies and calls for further research to establish evidence-based guidelines for managing such complex conditions.

Keywords: Cerebral infarction; Internal trapping; Multiple dissection; Subarachnoid hemorrhage.

Figure 1:

(a) Computed tomography showed a thick subarachnoid hemorrhage around the left vertebral artery (arrow). (b) Computed tomography angiography revealed dissections in the bilateral internal carotid arteries and vertebral arteries. The right internal carotid artery was occluded, while the left internal carotid artery showed a partial deficiency, likely due to a thrombus associated with dissection (arrow). Fusiform aneurysms were observed in both vertebral arteries. (c) Digital subtraction angiography demonstrated recanalization of the right internal carotid artery. (d) The left internal carotid artery had poor contrast (arrow). (e) The right vertebral artery displayed a fusiform aneurysm. (f) The left vertebral artery had a fusiform aneurysm with a bleb (arrow).

Figure 2:

(a) Internal trapping of the left vertebral artery aneurysm was performed using double catheter technique. (b) The aneurysm was packed tightly with coils.

Figure 3:

(a) Magnetic resonance imaging on the day after onset showed infarction in the right watershed region and left middle cerebral artery region. (b) Digital subtraction angiography showed the disappearance of a poorly contrasted area, which was suspected to represent a thrombus in the left internal carotid artery (arrow).

Figure 4:

(a and b) A follow-up digital subtraction angiography performed 22 days after onset showed a significant morphological change in the bilateral internal carotid arteries. (c and d) The bilateral vertebral arteries remained stable.